Provider Demographics
NPI:1932083961
Name:PROUD PEACEFUL NUTRITION, LLC
Entity type:Organization
Organization Name:PROUD PEACEFUL NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, REGISTERED DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:PROUD
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD
Authorized Official - Phone:319-331-9017
Mailing Address - Street 1:1720 SILVER MAPLE TRL
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-4740
Mailing Address - Country:US
Mailing Address - Phone:319-331-9017
Mailing Address - Fax:319-469-8763
Practice Address - Street 1:2751 OAKDALE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-9749
Practice Address - Country:US
Practice Address - Phone:319-331-9017
Practice Address - Fax:319-469-8763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health